Author: Amy Valasek, MD, MS
Editor: Richard Chang, MD, MPH
15 y/o Spanish speaking male presented one hour after twisting his left knee playing recreational soccer to outside urgent care.
He was reported as uncooperative and had significant pain lateral proximal shin. Two views of left knee radiographs demonstrated possible widening of tibia tubercle. The radiologist was suspicious for Type 1 avulsion fracture based on slight widening. However the urgent care physician did not feel this was the source of his injury and pain based on the exam. Pediatric sports medicine was then phone consulted. Further examination of hip, knee and ankle were discussed. Contralateral knee radiographs, ipsilateral tibia/fibula films, ipsilateral hip and femur films were recommended as further work up. After the discussion, only ipsilateral tibia/fibula films were completed. He was discharged with a left avulsion fracture tibia tuberosity, placed in knee immobilizer on crutches and planned to follow up with Orthopedics in one week. The pediatric sports medicine physician, initially phone consulted, noted the documentation of the visit and the discussed recommendations were not fully implemented. The patient was called the following day and brought into the office for evaluation. He and his family presented 20 hours after the initial injury to Pediatric Sports Medicine Clinic. He was in obvious distress, crying, diaphoretic and pain was rated 20/10
He was tearful and uncooperative on evaluation. After removal of the knee immobilizer, he began to scream in pain. Rapid evaluation of the left lower extremity noted: 3+ knee effusion, zero active or passive range of motion of the left hip, knee, and ankle, the lack of extensor mechanism, minimal tenderness tibia tuberosity, and taught swelling of the left shin. The anterior and lateral compartments of the left lower extremity were extremely firm. Capillary refill was 4+ and color of the left shin appeared pale. The dorsalis pedis and tibialis pulses were 1+.
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